| Objective:1.To quantify the characteristics of the upper urinary tract lithiasis and to establish the quantification evaluation system-- SHA.LIN pumc scoring system.2.To verify the reliability of the SHA.LIN pumc scoring system by testing its reproducibility between different observers.3.To explore the clinical significance and the value of the SHA.LIN pumc scoring system for assessing and predicting the SFRs and the incidences of complications after endoscopic lithotripsy for upper urinary tract calculus.4.To compared the accuracy of the SHA.LIN pumc scoring system and other stone score in the same cohort and to determine which was most predictive of the endoscopic lithotripsy outcomes.Methods:A literature review from 1976 to 2015 was performed to identify clinically relevant and reproducible variables that could affect the outcomes after endoscopic lithotripsy for upper urinary tract lithiasis and to establish the quantification evaluation system. Six reproducible variables available from preoperative noncontrast-enhanced computed tomography (NCCT) were measured:stone size(S),hydronephrosis(H), anatomic distribution(A), length of tract, lower calyx infundibulum pelvis angle or length of calculus from the pelvic outlet(L), indicator of CT(I), number of involved calices or stones(N) and that named SHA.LIN pumc scoring system.A retrospective analysis was conducted of clinical data of 1057 patients with endoscopic lithotripsy undergoing PCNL,RIRS or URL from June 2011 to Dec 2015 in Peking Union Medical College Hospital and Qingdao Fuwai Hospital. The general conditions, pre-operative information, stone characteristics and perioperative variables were collected.A single observer reviewed all images and assigned scores.The correlation of SHA.LIN pumc scoring system with stone-free status, operation time,blood loss,length of hospital stay and postoperative complications were analyzed.Receiver operating characteristic (ROC) curves was drawn to detect sensitivity and specificity of SHA.LIN pumc scoring system in predicting the stone-free rates of PCNL,RIRS or URL.The SHA.LIN pumc scoring system, the S.T.O.N.E. score, the Guy’s stone score and the RUSS score based on preoperative computerized tomography images were calculated. Logistic and linear regression analysis were performed and Receiver operating characteristic (ROC) curves were drawn to determine the most predictive scoring system. Preoperative images of 152 patients who underwent PCNL,80 patients who underwent RIRS and 80 patients who underwent URL were reviewed.Two surgical residents and two urology attending independently reviewed all images and assigned scores.Interobserver reliabilities of the total score for all categories and each component were evaluated by the intraclass correlation (ICC) and a k coefficient.Results:1.The interobserver reliability for the total score demonstrated high correlations for all components and total score (ICC= S,H,A,L,I,N and total 0.96,0.95,0.94,0.92,0.82,0.95, 0.95, respectively) in 152 patients who underwent PCNL, for all components and total score (ICC= S,H,A,L,I,N and total 0.96,0.94,0.95,0.88,0.91,0.99,0.96,respectively) in 80 patients who underwent RIRS and for all components and total score (ICC= S,H,A,L,I,N, and total 0.96,0.95,0.98,0.96,0.95,0.95,0.97,respectively) in 80 patients who underwent the URL. k rates for between two urology attending were 0.77,0.92,0.82,0.97,0.73,0.95 and 0.81 for the S,H,A,L,I,N components and total score in 152 patients who underwent PCNL, respectively. k values between the two urology attending were 0.91,0.83,0.95,0.84,0.75,0.97 and 0.88 for S,H,A,L,I,N components and total score in the 80 patients who underwent RIRS, respectively. k values between the two urology attending were 0.93,1,1,0.91,0.92,0.89 and 0.93 for S,H,A,L,I,N components and total score in the 80 patients who underwentURL, respectively.2.The SHA.LIN pumc score was 9.04±2.12 in PCNL’s cohort.The stone free rate was 75.5%(324/429).Postoperative complications occurred in 96(22.4%) cases.SHA.LIN pumc score,hydronephrosis, anatomical distribution of stones and number of involved calices showed significant correlation with the postoperative stone free status (P＜0.05).SHA.LIN pumc score showed significant correlation with the operation time,estimated blood loss,length of hospital stay (P<0.01),and it correlate with postoperative complications (P=0.002).The area under curve (AUC) of Receiver operating characteristic (ROC) curves for the SHA.LIN pumc scoring system was 0.917(95%C/0.886-0.948). In those patients with stone free, the SHA.LIN pumc score was 8.22±1.45, significantly lower than that in those patients with residual stones 11.56±1.85(t=-19.076, P=0.000).There was significant difference in the areas under the curves (AUC) for the SHA.LIN pumc score vs S.T.O.N.E. score (0.917(95%CI 0.886-0.948) vs 0.808(95%CI 0.757-0.860;P<0.001)) and for the SHA.LIN pumc score vs Guy’s stone score (0.917(95%CI 0.886-0.948) vs 0.726 (95%CI 0.669-0.782)); p<0.001).When the cutoff was determined 9 score, the sensitivity of SHA.LIN pumc scoring system was 86.67% and specificity was 86.42%.3.The SHA.LIN pumc score was 11.57±2.49 in RIRS’s cohort.The stone free rate was 66.3% (159/240). Postoperative complications occurred in 48(20%) cases. SHA.LIN pumc score, anatomical distribution of stones, indicator of CT and number of involved calices showed significant correlation with the postoperative stone free status (P＜0.05). SHA.LIN pumc score showed significant correlation with the operation time and length of hospital stay (P<0.05).The area under curve (AUC) of Receiver operating characteristic (ROC) curves for the SHA.LIN pumc score was 0.874(95%CI 0.831-0.916).In those patients with stone free, the SHA.LIN pumc score was 10.48±2.21, significantly lower than that in those patients with residual stones 13.70±1.40 (t=-11.950,P=0.000). There was significant difference in the areas under the curves(AUC) for the SHA.LIN pumc score vs RUSS score (0.874(95%CI 0.831-0.916) vs 0.831(95%CI 0.777-0.884);p=0.04). There was not significant difference in the areas under the curves(AUC) for the SHA.LIN pumc score vs S.T.O.N.E. score (0.874(95%C7 0.831-0.916) vs 0.861(95%CI 0.815-0.906);P=0.378). When the cutoff was determined 12 score, the sensitivity of SHA.LIN pumc scoring system was 79.01% and specificity was 77.99%.4.The SHA.LIN pumc score was 9.32±1.75 in URL’s cohort. The stone free rate was 87.9%(341/388).Postoperative complications occurred in 52(13.4%)cases. SHA.LIN pumc score, stone size,hydronephrosis, anatomic distribution of stones and length of calculus from the pelvic outlet showed significant correlation with the postoperative stone free status (P＜0.05). SHA.LIN pumc score showed significant correlation with the operation time and postoperative hospital stay (P＜0.05).The area under curve(AUC) of Receiver operating characteristic (ROC) curves for the SHA.LIN pumc score was 0.878(95%C70.827-0.928). In those patients with stone free, the SHA.LIN pumc score was 9.00±1.52, significantly lower than that in those patients with residual stones 11.62±1.57 (t=-11.021, P=0.000). There was significant difference in the areas under the curves(AUC) for the SHA.LIN pumc score vs S.T.O.N.E. score (0.878(95%C/0.827-0.928) vs 0.785 (95%CI 0.715-0.856); P<0.001). When the cutoff was determined 10 score, the sensitivity of SHA.LIN pumc scoring system was 78.72% and specificity was 84.46%.Conclusions:1.Due to the development of the endoscopic technology, it was necessary for the treatment of upper urinary tract lithiasis to establish SHA.LIN pumc scoring system. SHA.LIN pumc scoring system is a reproducible standardized classification system that quantitates the imaging information of upper urinary tract lithiasis based on the preoperative noncontrast-enhanced computed tomography(NCCT) and have elements that needs to fulfill 3 requirements:(1) score must be easy to compose from available preoperative noncontrast-enhanced computed tomography(NCCT) imaging;(2) the variables of score must provide detailed preoperative information for each case;(3) the scoring system can provide information regarding postoperative outcomes.2.SHA. LIN pumc scoring system was built that based on the technology of PCNL, RIRS, URL and the predictive ability of the SHA. LIN pumc scoring system was verified through the pre-experiment. SHA.LIN pumc score can be used for preoperative disease evaluation, evaluation of surgical outcomes,surgical planning and patient counseling.A single scoring system should be adopted to unify reporting of the clinical research and to guide the choice of the treatment.3.The research shows that the area under curve (AUC) of Receiver operating characteristic (ROC) curves for the SHA.LIN pumc scoring system was 0.917 (PCNL),0.874 (RIRS) and 0.878 (URL) and revealed that accuracy of the SHA.LIN pumc scoring system is relatively precise in predicting stonefree status after endoscopic lithotripsy for upper urinary tract calculus.4.The major limitation of our study was the small cohort of patients and retrospective analysis.Further multicenter randomized trials is required to evaluate its performance in predicting perioperative variables and to increase its value on clinical application for predicting the stone-free rate and postoperative complications. |
PDF Full Text Request